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NEUROIMAGE
Year : 2015  |  Volume : 63  |  Issue : 2  |  Page : 282-283

Chronic calcified extradural and subdural hematoma following a ventriculoperitoneal shunt placement


Department of Neurosurgery, Mohammed V Military Teaching Hospital, Mohammed V University, School of Medicine, Hay Riyad, Rabat, Morocco

Date of Web Publication5-May-2015

Correspondence Address:
Dr. B O Djoubairou
Department of Neurosurgery, Mohammed V Military Teaching Hospital, Mohammed V University, School of Medicine, Hay Riyad, 1018 Rabat
Morocco
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.156316

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How to cite this article:
Djoubairou B O, Gazzaz M, Dao I, Mostarchid BE. Chronic calcified extradural and subdural hematoma following a ventriculoperitoneal shunt placement. Neurol India 2015;63:282-3

How to cite this URL:
Djoubairou B O, Gazzaz M, Dao I, Mostarchid BE. Chronic calcified extradural and subdural hematoma following a ventriculoperitoneal shunt placement. Neurol India [serial online] 2015 [cited 2019 Oct 21];63:282-3. Available from: http://www.neurologyindia.com/text.asp?2015/63/2/282/156316


A 22-year-old man was admitted with headache and vomiting but without any visual loss. His past history revealed placement of a medium pressure ventriculoperitoneal shunt (VP) at another hospital for the management of congenital hydrocephalus. He was not on regular follow up at that hospital but continued to be well despite the presence of a persisting learning difficulty since childhood. At admission, there was no past history of head injury. He was conscious and showed a mild mental retardation. There was neither loss of visual acuity nor the presence of papilledema. A cranial X-ray showed a parieto-occipital chronic calcified hematoma with presence of a ventriculoperitoneal shunt [Figure 1]a. His cerebral computed tomography (CT) showed a coexisting right parieto-occipital, chronic calcified extradural hematoma (CEDH) and a chronic calcified subdural hematoma (CSDH) associated with congenital hydrocephalus [Figure 1]b. His magnetic resonance imaging [Figure 1]c confirmed the associated subdural and extradural hematoma. Due to the absence of progressive neurological deficits and of intracranial hypertension, he was placed on analgesics that provided symptomatic relief in his symptoms within 5 days. He has been on a regular follow-up. At a follow-up of 3 months, he showed neither any recurrence of his previous symptoms nor of neurological deterioration.
Figure 1: (a) Cranial X-ray showing the parieto-occipital chronic calcified hematoma and the presence of ventriculoperitoneal shunt; (b) Coronal CT scan parenchymal window confirming the right sided parieto-occipital chronic calcified extradural and subdural hematoma associated with congenital hydrocephalus; and, (c) Axial T1 MRI showed right-sided parieto-occipital chronic calcified extradural and subdural hematoma without any signs of an active hydrocephalus

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A CSDH caused by over-drainage of the cerebrospinal fluid (CSF) consequent to a CSF diversion procedure is a well known entity and occurs in approximately 0.3-2.7% cases. [1] The incidence of CEDH is between 3.9 and 30%. It occurs more commonly in the younger age group due to the presence of lax adhesions between the dura and the calvarium. [2] To the best of the authors' knowledge, the simultaneous association of a CEDH and CSDH in a patient has not been reported till date. The pathogenic mechanisms responsible for the occurrence of calcification remain unclear. The currently proposed mechanisms include the presence of a poor circulation leading to lack of absorption of the hematoma in the subdural and extradural spaces associated with intravascular thrombosis. The insufficient arterial supply as well as inadequate venous return led to the presence of stagnant blood that subsequently underwent calcification. [3],[4] Rapid ossification of a post-traumatic extradural hematoma in a child could be due to the occurrence of disproportionate repair of tissues following an acute injury. It has been postulated that damage to highly vascular tissues such as bone and dura initiates a tissue response that includes inflammation, repair, and remodeling. This natural sequence of the healing process is more rapid in children than in adults. [5] The occurrence of calcification in the case of a CSDH may be due to the presence of microscopic calcium deposits within the membranes of the hematoma that may proceed to extensive calcification and even ossification. An underlying metabolic abnormality that promotes calcification is another contributory factor. [6] The treatment remains a subject of controversy. Patients who are asymptomatic, elderly, or without progressive neurological deterioration may be managed conservatively. [4],[6] The steps to prevent this complication include minimal CSF drainage at the time of placement of the ventricular catheter, a meticulous surgical technique, performance of a check CT scan after surgery (to ensure the absence of a postoperative hematoma), a gradual return of the patient to an upright position during postoperative nursing, and maintenance of a close watch on them following their successful discharge.

 
  References Top

1.
Sharma RR, Mahapatra A, Pawar SJ, Sousa J, Athale SD. Symptomatic calcified subdural hematomas. Pediatr Neurosurg 1999;31:150-4.  Back to cited text no. 1
    
2.
Jain SK, Sundar IV, Sharma V, Arora R, Prasanna KL. Chronic ossified extradural hematoma on the opposite side of the ventriculoperitoneal shunt procedure: A rare case report. Saudi J Health Sci 2012;1:159-61.  Back to cited text no. 2
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3.
Juan WS, Tai SH, Hung YC, Lee EJ. Multiple tenting techniques improve dead space obliteration in the surgical treatment for patients with giant calcified chronic subdural hematoma. Acta Neurochir 2012;154:707-10.  Back to cited text no. 3
    
4.
Taha MM. Armored brain in patients with hydrocephalus after shunt surgery: Review of the literature. Turk Neurosurg 2012;22:407-10.  Back to cited text no. 4
    
5.
Dawar P, Phalak M, Sinha S, Sharma BS. Same side double chronic calcified epidural hematoma: Case report and review of the literature. Neurol India 2013;61:195-7.  Back to cited text no. 5
[PUBMED]  Medknow Journal  
6.
Garg K, Singh PK, Singla R, Chandra PS, Singh M, Satyarthhe GD, et al. Armored brain-massive bilateral calcified chronic subdural hematoma in a patient with ventriculoperitoneal shunt. Neurol India 2013;61:548-50.  Back to cited text no. 6
[PUBMED]  Medknow Journal  


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This article has been cited by
1 A Tortuous Process of Surgical Treatment for a Large Calcified Chronic Subdural Hematoma
Huan Li,Xiang Mao,Xiao-Gang Tao,Jing-Sheng Li,Bai-Yun Liu,Zhen Wu
World Neurosurgery. 2017; 108: 996.e1
[Pubmed] | [DOI]



 

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